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  <title>自贡市疫情报备系统</title>
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</head>

<body>
  <div id="container" class="container animated fadeInUp">
    <div class="row">
      <div class="col-sm-6 col-xs-12 loading"></div>
    </div>
  </div>
  <div id="form" class="form animated hidden">
    <div class="container">
      <div class="row">
        <div class="col-sm-6 col-xs-7 report">
          <h3 class="form_head">疫情报备</h3>
          <form id="report_form" class="report_form">
            <div class="first">
              <div class="flexbox">
                <div><span>姓名</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div><input class="input" type="text" name="username" placeholder="请输入姓名"></div>
              </div>
              <div class="flexbox">
                <div><span>性别</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div><input class="input" type="text" name="sex" placeholder="请输入性别"></div>
              </div>
              <div class="flexbox">
                <div><span>手机号</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div><input class="input" type="number" name="phone" placeholder="请输入手机号"></div>
              </div>
              <div class="flexbox">
                <div><span>身份证号</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div><input class="input" type="text" name="IDCard" placeholder="请输入身份证号"></div>
              </div>
            </div>
            <div class="first">
              <div class="flexbox">
                <div><span>到达区县</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div><input id="country" class="input" type="text" name="country" placeholder="请输入到达区县" readonly></div>
              </div>
              <div class="flexbox">
                <div><span>家庭住址</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div><input class="input" type="text" name="detail_address" placeholder="请输入详细住址"></div>
              </div>
              <div class="flexbox">
                <div><span>返回日期</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div><input class="input" type="text" id="return_date" name="return_date" placeholder="请输入返回日期"
                    readonly></div>
              </div>
            </div>
            <div class="two">
              <div class="flexbox">
                <div><span>是否接触病例人员</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div>
                  <select name="contact_cases" id="contact_cases" class="contact_cases">
                    <option value="0" selected>否</option>
                    <option value="1">是</option>
                  </select>
                </div>
              </div>
              <div class="flexbox">
                <div><span>是否发热、咳嗽症状</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div>
                  <select name="fever_cough" id="fever_cough" class="contact_cases">
                    <option value="0" selected>否</option>
                    <option value="1">是</option>
                  </select>
                </div>
              </div>
              <div class="flexbox">
                <div><span>有无其他症状</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div>
                  <select name="other" id="other" class="contact_cases">
                    <option value="0" selected>否</option>
                    <option value="1">是</option>
                  </select>
                </div>
              </div>
              <div class="flexbox">
                <div><span>是否48小时核酸报告</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div>
                  <select name="nucleic_Report" id="nucleic_Report" class="contact_cases">
                    <option value="0" selected>否</option>
                    <option value="1">是</option>
                  </select>
                </div>
              </div>
              <div class="flexbox">
                <div><span>有无新冠疫苗接种</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
                <div>
                  <select name="inoculation" id="inoculation" class="contact_cases">
                    <option value="0" selected>否</option>
                    <option value="1">是</option>
                  </select>
                </div>
              </div>
              <div class="flexbox">
                <div><span>返回行动轨迹</span><i class="fa fa-star icon" aria-hidden="true"></i></div>
              </div>
              <div class="action">
                <textarea class="action_track" name="action_track" id="action_track" cols="26" rows="4"
                  placeholder="填写返回行动轨迹，例如：早上8点30乘坐高铁，9点30到达高铁站...."></textarea>
              </div>
            </div>
            <button type="submit" class="submit">立即报备</button>
          </form>
        </div>
      </div>
    </div>
  </div>
  <div id="success" class="success animated hidden">
    <div class="container">
      <div class="row">
        <div class="col-sm-6 col-xs-6 success_div">
          <div class="success_img"></div>
          <div class="text">已报备成功</div>
        </div>
      </div>
    </div>
  </div>
  <script src="./plugins/seajs/sea.js"></script>
  <script src="./js/config.js"></script>
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  <script src="./plugins/jquery/jquery-3.6.0.js"></script>
  <script src="./plugins/jquery_form/jquery.form.js"></script>
  <script src="./plugins/showText.js"></script>
  <script src="./plugins/Calendar/calendar.js"></script>
  <script src="./plugins/Larea/LArea.js"></script>
  <script src="./js/form.js"></script>
</body>

</html>